Treating Unintentional Weight Loss Nutrition Options: An Important Piece of the HIV Puzzle
Unintentional weight loss has long been recognized as a reason for concern in people living with HIV/AIDS (PLWHA). Both studies and experience have helped us to understand that unintentional weight loss can be a signal of a potential secondary problem and ultimately an indication of increased risk for disease progression and poor outcome.
Different factors contribute to unintentional weight loss and malnutrition. Unintentional weight loss can result from starvation, a condition called cachexia, or a combination of the two.
Starvation is a form of weight loss that occurs because of decreased intake of calories and protein. It can also occur in an individual who is eating enough, but who is losing many calories because of altered bowel function and diarrhea, more commonly referred to as malabsorption. Starvation can result from a combination of both decreased intake of food and increased calorie losses. If the bowel can absorb normally, starvation can be corrected by increased intake of calories and protein. If the bowel cannot absorb normally, then the reason for the bowel problem needs to be identified and the problem corrected, so the individual can eat and absorb nutrients. Initially, starvation mainly causes a decrease in body fat, rather than skeletal muscle. If starvation progresses over a long period of time, more muscle tissue will be lost and the individual will begin to experience loss of body muscle or "wasting."
Cachexia differs from starvation. The loss of weight is mostly from loss of muscle tissue, known as a loss of "Lean Body Mass" (LBM) or "Body Cell Mass" (BCM). Both the muscle and protein tissues in our body are the tissues in which most of our metabolic function occurs, including immune tissue, organ tissue, tissue that produces energy and support movement, and tissue that supports body functions. No protein tissue can be considered storage tissue. All protein tissues have a role and are part of body function homeostasis or balance. Loss of LBM alters the balance and can affect the body functions that support maintenance of optimal health. Cachexia is caused by metabolic alterations. These metabolic alterations affect how the body uses the nutrients that come from food. The end result of cachexia is that the body uses protein tissues for energy. When an individual suffers from cachexia simply eating adequate protein, calories and micronutrients may not reverse this form of unintentional weight loss. This is defined as "wasting syndrome."
Designing a Treatment Plan
Weight loss can be caused by a number of factors including:
Identifying the cause of the weight loss is the first step in developing an appropriate treatment plan. Whether the cause is related to decreased intake, increased nutrient losses or changes in metabolic function, nutrition plays an important role in stopping the weight loss, and in regaining lost weight and lost LBM.
Both food and food supplements can play a valuable role in developing a successful treatment plan. The use of oral supplements can be particularly useful when an individual is unable to take in food as a source of calories and protein because of difficulty with chewing, swallowing and fatigue. Additionally, in the real world, not all people will take the time (or have the time) to prepare meals properly (even when they can), and in these instances supplements can also be helpful to those individuals. Second line nutrition supplements, which include micronutrient supplements or amino acid supplements, can also be useful in specific situations to support the treatment of weight loss. We know that specific foods and nutrition supplements are helpful to specific symptom management such as diarrhea, decreased intake, or when a patient is wasting secondary to metabolic changes. Research continues to help us understand options for nutrition and its role in conjunction with medical care, in treating unintentional weight loss.
Adequate Calories, Protein and Micronutrients
The first line in nutrition treatment for unintentional weight loss is assuring the intake of adequate calories, protein and micronutrients, preferably from food. However, both medical symptoms and social conditions can affect an individual's ability to eat enough food to meet optimal energy and nutrient needs. Side effects of HIV/AIDS and/or medications can cause symptoms such as nausea, vomiting, and diarrhea, thereby also making the consumption of adequate nutrients difficult. In addition, alterations in metabolism can cause increased energy needs. Other issues such as economic and social conditions, including a physical inability to prepare meals can also affect the ability to eat properly. All of these symptoms and conditions can affect intake, in addition to making one feel overwhelmed by attempting to eat what appears to be so much.
Depending on the specific symptom(s), dietary intakes can be adjusted to help manage the symptoms. Examples of dietary strategies for diarrhea symptom management include:
If an individual needs to add calories and protein, other strategies can come into play. Altering your meal plan to include 6 small meals per day can be helpful, as well as the inclusion of high calorie, high protein nutrient dense snacks. Suggestions for such foods include:
You can also whip up healthy shakes with milk or soymilk, yogurt, sherbet, wheat germ, fruit nectar or ice cream. If you are lactose tolerant, adding dried milk powder to shakes, soups, and milk is also a great way to add extra calories and protein. Work with your dietitian to find creative, simple ways to add extra calories and protein to your meals and to identify strategies for meal planning that meet your individual needs.
Commercial Nutrition Supplements
A number of commercial nutritional supplements are also available and can help a person living with HIV/AIDS (PLWHA) gain back lost weight. Studies have been conducted that support use of nutrition supplements to induce weight gain. However, it is important to differentiate weight gain from gain of BCM or lost lean tissue. In the case of significant losses of lean tissue (LBM), the goal is to regain the lost lean tissue. Clinical studies performed to evaluate the effect of using oral liquid supplements on weight gain and body cell mass have produced conflicting results. Some studies have shown weight gain only in fat tissue. Others conclude with no weight gain. Still others claim an increase in both weight and BCM. In choosing a supplement consideration should be given to a number of things, including presence of diarrhea, lactose intolerance, individual nutrient requirements, and taste, as well as weight gain and body cell mass goals.
For those who are lactose tolerant, instant breakfast mixes or sports shakes are an inexpensive alternative. They can also be mixed with soy milk or lactase treated milk. In the presence of diarrhea, a low fat supplement, one with MCT oil, and a semi-elemental formula might be the best choice. The amino acid glutamine is also commonly used to manage diarrhea, which can be helpful in managing weight loss when the loss is associated with altered GI function and malabsorption. There are also juice-based supplements on the market. (See list)
Other supplements, known as modulars, are commonly used for weight gain. A clinical study completed in 1999 used a product called Immune System Booster (now called Syst-amune, Baxter Healthcare). This product contains a combination of glutamine, N-acetyl-cysteine, and micronutrients. Another glutamine based product, Juven (MTI BioTech), has also been used in trials to enhance lean body mass in PLWHA. Other modular products being marketed for weight gain include whey protein based products, as well as sports powders that include combinations of creatine, glutamine and taurine.
Research in nutrition including HIV positive participants has informed our understanding of the different nutritional needs of HIV positive and negative individuals. It has also demonstrated the correlation between nutrition, quality of life and managing disease progression. Malnutrition, weight loss, and lost lean body mass have been associated with poor patient prognosis and should be aggressively managed. Once lost, it can take 10 times longer to gain back lost weight and lost body cell mass. Because the causes of unintentional weight loss are so variable, treatment plans should be individualized and based on the cause of the lost weight, as well as goals for regaining both lost weight and lost lean body mass.
Nutrition is one key piece of the medical management puzzle of HIV and the treatment for lost weight in conjunction with medications, exercise, and other medical management. Addressing unintentional weight loss proactively and vigorously can improve the overall health and outcomes for PLWHA. A Registered Dietitian can help you develop a sound nutrition plan, as well as assist you in selecting supplements that might be helpful in support of your nutrition, weight gain, and BCM goals.
Denise DeTommaso is a Registered Dietitian with a wide range of experience in clinical dietetics, teaching and industry. She recently left her private HIV/AIDS practice to relocate. She currently lives in Lawrence, Kansas and is employed at Lawrence Memorial Hospital and as a Nutrition consultant to Baxter Healthcare. She can be reached at firstname.lastname@example.org. References are available from author upon request.
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